Wednesday, June 28, 2017

Healthcare Wars 2017 Part 2 - What Did I Just Tell You About That Pony?

At least until somebody writes a bill they can read
Single payer. Two words, a simple concept. There are variations, but the core principle is that every citizen is entitled to free health care, and the government sets up a system for paying the costs incurred with public funds. It's really two pieces - there is the insurance, or payment side, and the delivery side. On the payment side, it's easy - mostly. Just like Medicare or Social Security, the government merely sets up a straightforward bureaucracy to make the payments to doctors, hospitals, dentists, nurses, specialists, pharmacies and the rest of the health care delivery infrastructure. Because the government is a monopsony - the only buyer on the market - they can set their payment/reimbursement rates at any level they choose, much like a monopoly can set prices for their goods at any level regardless of market imperatives. The only 'challenging' portion of this part of the process is to raise the funds.

The other side of the Single Payer question in America is how to make the current privatized delivery system work in this new publicly funded process. Private for-profit insurance companies would just die - quickly - because no one would need to purchase insurance anymore, and only wealthy people would buy policies that provided them with access to better service than the public delivery infrastructure. So, somehow, in a free market in a democratic nation, the government would have to take control of virtually every doctor, hospital, pharmacy, dental office - trillions of dollars, millions of people - and then pay them a fraction of what they are used to receiving in the current for-profit private health care world.

So, when you think about it, it's hard to imagine what this single payer legislation would look like. You'd end up with a whole bunch of unemployed people in the private insurance industry, and whole bunch of doctors and hospitals that simply refused the government's mandated payment rates, only accepting patients from the remaining private insurers that paid full freight. And you'd end up with a massive constitutional problem - you can't privatize the health care delivery industry, and you can't force them to take patients they don't want.

And, of course, there's getting the people to buy in. 80% of Americans get their health insurance as part of their employment. That means they pay for insurance with lower wages, but that's baked into the cake by now. So they never see an actual insurance bill, and their only out-of-pocket expenses are deductibles and co-pays to their delivery providers. So now, if we come skipping up with our bright, progressive smiles and tell them that they're going to get a somewhat poorer - but perfectly acceptable - level of coverage, and we're only going to raise their income taxes 35% to give it to them, do you really think they're going to get really excited and tell their representatives to make it so?

See, that's what a pony looks like...

Tuesday, June 27, 2017

Healthcare Wars 2017 Part 1 - No, You May Not Have a Pony

And everybody gets a vote
The latest political battle over healthcare policy in the US is raging as debate over the Senate healthcare bill is extended through the summer recess. And the outpouring of outrage and resistance from the sane portion of the electorate is wonderful to see. But this bill (like the version the House passed last month) is deeply, desperately unpopular, with favorable polling running at below 20%. That means there are a LOT of Americans who are far from being politically liberal who are concerned for the well-being of their families and fighting just as hard as we are.

All of which gives us an opportunity to think about our political ideology and the belief system in which it operates. Last year, in the presidential primaries, there was a strong liberal cohort that was all in behind Bernie Sanders. Now, I'm not going to go back through all the problems with the Sanders campaign and message, but there is a larger point that is critically important to recognize at this point. That point is simply this - the other side has a vote too. Now, everyone you know might be politically liberal and broadly welcoming of tax increases to improve the lives of our fellow citizens, but that is not true of the population as a whole. Much of the nation is deeply suspicious of liberal economics, 'tax and spend' policies that have been deeply maligned by general consensus over the decades. Everyone from far-right tea party wingnuts to suburban 'social liberal/fiscal conservatives' are going to fight us every step of the way on any movement away from America's very limited activist government and safety net. There are more of them than there are of us.

You can demand single payer healthcare, tuition-free colleges (not even in the federal jurisdiction), Universal Basic Income and humane immigration policies all you want, but you're never going to get them. You do all the work - and get a little luck - you might just get some compromise, watered down version that improves everyone's life. Kind of like the ACA. In America, corporations make a profit by selling you a cure when you're sick or injured. That system is deeply entrenched, which is why American healthcare costs are so much higher than they are elsewhere in the world. Given time, favorable politics and a HUGE effort, President Obama was able to push through the greatest breakthrough in American healthcare in history. But make no mistake, it was a compromise, necessitated by the fact that every stakeholder in the system wasn't a liberal.

Here's the point. Liberals aren't going to get elected in America demanding far left policies, as much as we want them and believe that they are the right thing to do. When liberals DO get elected, they aren't going to be able to force those same policies through a system with as much friction and as many veto points as ours. And don't tell me we just need to take control of both houses of congress - even if the Democrats do that, it won't result in congress being populated by liberals. There will be Democrats from across the political spectrum, and most of them will not be in favor of the kinds of policies that Bernie Sanders championed. We have to recognize reality, accept that we're going to have to negotiate, compromise and accept incremental improvements in the system. There's no magic potion, there's no sparkle, there's no pony. The US is a huge nation with a huge diverse population, a nation that has in recent history elected both GW Bush and Donald fucking Trump.

Pretending is not a strategy. Understanding reality, and working within its constraints is the best we can do. And when we remember that, we do pretty well - from the ACA to the Iran nuclear deal to DACA - and when we forget it we get our political asses handed to us, and we get things like this horrific health care legislation. We can do better when we get serious...